Provider Demographics
NPI:1497464804
Name:GREEN, BRANDON PHILLIP
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:PHILLIP
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28520 WOOD CANYON DR APT 67
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5270
Mailing Address - Country:US
Mailing Address - Phone:510-828-7183
Mailing Address - Fax:
Practice Address - Street 1:17906 PIONEER BLVD UNIT 101-102
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3972
Practice Address - Country:US
Practice Address - Phone:562-865-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3031592251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty